Good Medicine

By Su Byron | January 1, 2009

Smile! It's the Future Admit it. Some of you fear dentists. OK, let’s be really honest—most of us harbor some fear of dentists. The scary image in our minds is a combination of ancient quacks with iron pliers and that unpleasant scene from Marathon Man. The truth is, until the... Read more »

Smile! It's the Future

Admit it. Some of you fear dentists. OK, let’s be really honest—most of us harbor some fear of dentists. The scary image in our minds is a combination of ancient quacks with iron pliers and that unpleasant scene from Marathon Man. The truth is, until the past few decades, dentistry has been pretty primitive.

Relax. That was then, this is now. Dentistry in the 21st century need not inspire fear. Today, teeth can be filled without drills. Computer-assisted design programs allow dental professionals to design and build porcelain veneers, crowns and other oral fixtures in-house and in one day. Digital radiology and CAT scan technology explore the mouth in greater detail than ever before. Problems beneath the surface can be fixed on a cellular level. And, within the next 10 years or so, some scientists claim that teeth will be able to regenerate themselves.

We asked some area dentists how they are using the latest technology. Here’s what they had to say.

Futuristic Foundations: Growing new gums

Like a house, teeth need a firm foundation—the areas of bone and gum, which anchor the teeth. If the foundation is unhealthy, the tooth will fail. Periodontal disease can lead to bone and gum defects. Until this past decade, there was little medical science could do about it. But now that science, which involves stem cell research, has afforded clinicians and periodontal surgeons the opportunity to repair lost gum and bone.

Board-certified periodontist N. Joseph Farris, DDS, has been working with this technology for the past five years. Farris is trained to surgically treat the effects of periodontitis (destruction of gingiva and supporting bone) in the oral cavity. For some patients with bone defects caused by periodontal disease, Farris works with a cutting-edge product called the GEM 21S, a synthetic grafting system for bone and periodontal regeneration. The product provides a biological component that attracts the specific cells our body needs to regenerate bone and the surrounding tissues, causing them to multiply in number. In essence, the system coaxes progenitor cells to actively heal and regenerate bone and tissue and create a structure that supports repair and regeneration of lost periodontal tissue.

And all that is pretty darn futuristic-sounding.

“The GEM 21S is an exciting application of stem cell science,” says Farris. “We now have evidence that in properly selected patients, we can potentially restore lost dental supporting bone, in addition to reversing gingival recession.” Farris stresses that this application stems from intensive evidence-based therapy, which means that the procedure has been clinically researched and showcased in peer-reviewed journals; by the time the treatment reaches the patient, years of trials have been conducted.

Even better? Farris explains that the surgical procedure is most often performed using dental anesthetic in a painless one-hour appointment and that post-operative discomfort is minimal and results are often visible within weeks.

The next step after regenerating lost periodontal tissue and bone is, of course, the restorative work: rebuilding the teeth and bridgework. In this area, Farris works with highly trained restorative dentists and prosthodontists to create a holistically healthy dental environment. One of the main players, or, as Farris dubs him, the “quarterback” of this specialized team is Howard Chasolen, DMD, a Sarasota-based prosthodontist.

Advances in restorative dentistry

A prosthodontist is an American Dental Association-recognized specialist in tooth restoration and replacement; in essence, a bio-architect and bioengineer of cosmetic, functional and implant restorations. This type of dental specialist is a rare breed in most communities, since the license requires thousands of hours of extensive training, education, residencies and fellowships. Prosthodontic training stresses the cosmetic as well as the functional aspects of dental reconstruction, and Chasolen works regularly with complex restorations of the whole mouth.

What’s new in restorative dentistry?

According to Chasolen, one of the more recent advances is metal-free dentistry. Until recently, he explains, our options for crowns (sometimes referred to as caps) were limited to restorations made with a metal substructure. A porcelain outer layer was fused to a thimble of metal beneath the porcelain, providing strength and support for the porcelain. And, although these restorations were strong, they often resulted in less than optimal cosmetic outcomes as well as tissue reactions to certain base metals used in the procedure. Additionally, and equally important, the metal substrated crowns were often cemented rather than bonded. Dental cements can be soluble, resulting in an eventual micro-opening at the junction of the crown and the tooth. This is similar to the deterioration of caulk in a joint.

An alternative? Eliminate the metal substrate and create a crown from an advanced substrate material.

“Ceramic crowns have been around for decades, but lack of strength has been an issue with the early generation of ceramic crowns,” says Chasolen. Fortunately, today’s chemists and materials scientists have created ceramic dental restorative materials with extraordinary strength and beauty.

“Early studies are showing promise at the five-year observation period, and we are experiencing less material fracture with the new ceramics than those of the past,” says Chasolen.

These new tough materials include lithium disilicate (glass ceramics comprised of lithium oxide, silica and other materials) and high-tensile-strength zirconium oxide ceramics. Crowns incorporating these materials can be created traditionally or be milled using CAD computer technology.

Hang around Chasolen for an hour or two and you may find yourself getting excited by lithium disilicate, too. He glows with enthusiasm as he tries to explain it in layman’s terms.

“When we use the zirconia-based ceramics, we lose the ability to bond the crown; and there have been issues of porcelain veneer material delaminating from the zirconia substrate resulting in failure,” he says. “I’m excited about the lithium disilicates because the outcome is incredibly beautiful as well as foundationally strong. And I like the process of bonding the crown rather than cementing one.” To provide a dramatic result, veneers made of the same high-strength materials can create a uniform cosmetic appearance when a combination of crowns and veneers is needed. They can also be used on dental implants.

But Chasolen cautions that an outstanding cosmetic outcome is only as predictable as the foundation it rests on.

“The technology and materials are very promising. But they are not indicated for every clinical situation. Often, my mature adult patients present with existing crowns or large fillings that need to be replaced. Before a cosmetic reconstruction can be completed, we need to ensure that the gum and bone health is optimal. Without healthy gums, the new crowns may look wonderful for a period of time, but the foundation is bound to fail. If one has thin gum tissue or recession, a periodontist [gum specialist] is a vitally important part of the treatment.”

Instant Gratification: Crowns in a Day

For those patients whose gums and bones are healthy and who only need a crown or veneer, the waiting game is over, thanks to the CEREC, a revolutionary new computerized system that allows dentists to produce a ceramic veneer, crown, or inlay in one day. Mitchell Strumpf, DDS, is a fan of the CEREC.

Strumpf explains that, until recently, there was one basic option for making a crown or dental restoration—the mold technique. Dentists created an impression of the problem tooth with elastic materials. They sent the impression to a lab that used it to re-create the missing part of the tooth that would perfectly fit into the part of the tooth that was left. The wait time was two to three weeks. In the meantime, the patient would walk around with a temporary crown. “You were at the mercy of the lab,” Strumpf says.

In his office, there’s no mold and very little wait. It’s all done in-house. “We take optical impressions instead,” he explains. As part of the CEREC system. Strumpf uses computerized tomography (CT), X-ray equipment and cutting-edge software to create detailed scans of teeth, bones and soft tissues. “That way, there’s no guesswork,” he says. “Based on these scans, we’re able to design the patient’s crown on the spot and transmit it to a milling machine. We place a porcelain block inside it that matches the shade of the patient’s teeth. It takes about 10 minutes to fabricate the crown. It’s clearly the wave of the future.”

Neuromuscular Dentistry: A Whole System Approach

Neuromuscular dentistry is an emerging field of dentistry that considers the alignment of the facial muscles and nerves and the correct positioning of the jaw as the basis for treating a range of conditions, including temporomandibular joint syndrome (TMJ), migraines, neck and shoulder pain, jaw pain, clicking or popping in the jaw, and tinnitus (ringing in the ears). Essentially, a neuromuscular dentist thinks in terms of verbs, not nouns. They look at teeth as part of a whole system, i.e. the skull, jawbone, and facial muscles affected by biting and chewing.

Jill Morris, DMD, specializes in neuromuscular dentistry. She’s also an instructor at the Las Vegas Institute for Advanced Dental Studies, teaching dentists and lab technicians from around the country.

“Neuromuscular dentistry looks at the relationship between the muscles of the jaw, the joint of the jaw and the position of the teeth,” says Morris. “Misalignment in any of these locations has a direct effect on the whole system of opening and closing the jaw.”

To fix problems and alleviate pain, a neuromuscular dentist measures the whole system in action with sophisticated technology. Morris’ technological arsenal includes computerized jaw tracking instruments to record jaw movement, resting position and path of closure. She uses electromyography (EMG), to record the jaw’s muscular impulses; sonography, to detect the pops and clicks of a misaligned jaw; and X-rays to evaluate the condition and positioning of the joint.

“We conduct a meticulous exploration of the structure of the entire region,” she says. “As a result, we get the whole picture. The days of working in the dark are over.”

Getting to the Root of the Problem

Since the early 1980s, dental implants have been used extensively to restore missing teeth. Until recently, the implant procedure took several months. The dental specialist first placed the implant in the bone and then waited several months for the bone to heal before placing the crown on top. But in recent years, with the advent of 3D computerized tomography (CT) scanning techniques, dentists are able to model and plan the restoration visually from start to finish, thereby lessening the time in the dentist’s chair. While most implants are still performed mainly by oral surgeons, prosthodontists and periodontists, a growing number of general dentists take dental implant courses in order to provide this service.

Burr Bakke, DDS, cautions that implant surgery is not for every patient. “Healthy gums are a must,” he says. Like the other professionals we spoke with, Bakke depends on precise measurements and computer imaging to perfect his craft.

“I rely on the i-CAT,” he explains. This advanced cat-scan imaging system creates a three-dimensional image of the patient’s actual jaw. “It allows me to see the width, height and density of the bone and exactly where the nerves and the blood vessels are. I know exactly where the implant needs to go and what dimensions it should be.”

For some patients who are replacing just one tooth or a few teeth, Bakke is able to perform the implant procedure and provide temporary replacement teeth in one day. Bakke notes that the success rate for implants is constantly improving.

“This is cutting-edge technology,” he says. “But it’s rooted in decades of research and rigorous training. Thanks to our imaging system, we know exactly what we’re doing before we do it. We control the outcome—and we follow up and monitor our patients after the procedure. With proper care, implants can last a lifetime.”

Enlightened Products for Enlightened Consumers

According to Richard Greenspan, DDS, home dental care and preventive maintenance products are moving beyond fluoride toothpaste and dental floss. His concern is the precondition of dental decay and gum disease. The villain is, of course, processed sugar.

“People love it,” says Greenspan. “Unfortunately, bacteria love it as much as we do.” According to Greenspan, there’s a sweet alternative without the dark side. “Xylitol is a naturally occurring sugar without the bad effects of pure, refined sugar. The human body can use it, but the bacteria that cause gum disease and cavities can’t. It stops them from producing acids and other compounds that hurt the gums.”

Greenspan says that Xylitol also contains anti-cariogenic properties that help prevent tooth decay. The ingredient has also been shown to strengthen tooth enamel and has been linked to bone re-mineralization.

For his patients who crave sweets, Greenspan recommends Dr. John’s Candy Co. (drjohns.com), founded by Dr. John Bruinsma, a dentist in Grand Rapids, Mich. The company produces a wide variety of sugar-free candies, most of which contain Xylitol. Greenspan also works with the Bradenton-based Healthy Chocolate company (4noguilt.com) for chocoholics who can now enjoy sugar-free chocolate made with Xylitol.

Other new products include oral probiotics, which boost the mouth’s good bacteria, and a range of calcium and other dietary supplements that help fight gum disease and promote healthy bones, gum tissue and teeth.

What do they all have in common? Greenspan notes that while home dental care has traditionally focused on keeping your mouth clean, newer products are based on a holistic model.

“By all means don’t stop brushing, flossing and rinsing,” he says.

Keep Smiling

This isn’t science fiction—it’s all happening now. In the not too distant future?

Within the decade, instead of filling cavities, dentists might be able to regenerate teeth. Materials scientists are beginning to find just the right solutions of chemicals to rebuild decayed teeth, rather than merely patching their holes. A recent article in the Journal of Structural Biology examines the possibility of regrowing dentin with the aid of a calcium-rich solution of ions. According to the study cited, Sally Marshall, a researcher and professor at the Vision of Biomaterials and Bioengineering at the University of California San Francisco, has successfully remineralized some parts of damaged teeth; she is currently studying ways to make calcium crystals grow throughout the dentin. Beyond these baby steps, nanotechnology and genetic engineering offer the promise to not only regenerate teeth but regrow them—but that is still the distant future.

Whatever happens, area dentists will be riding the wave of change.

Eight Steps to Dental Health

1 Understand your own oral health needs: Your oral health depends on many factors, including what you eat, the type and amount of saliva in your mouth, your habits, your overall health and your oral hygiene routine. Changes in your overall health status often result in changes in your oral health.

2 Commit to a daily oral health routine: Talk to your dentist about your oral health practices. Based on the discussion, come up with an effective routine. It should be easy to follow and should take your situation into account. For example, if you are taking medicine that dries your mouth, you may want to use fluoride every day. Pregnant women, people with health conditions such as diabetes and people with braces also may want or need special daily care.

3 Use fluoride products: Everyone can benefit from fluoride, not just children. Fluoride strengthens developing teeth in children. It also helps prevent decay in adults and children. Toothpastes and mouthwashes are good sources of fluoride. Your dentist can prescribe a stronger concentration of fluoride in a gel, toothpaste or rinse if you need it.

4 Brush and floss to remove plaque: Everyone should brush at least twice a day. It’s even better to brush three times a day or after every meal. In addition, you should floss at least once a day. These activities remove plaque, which is a complex mass of bacteria that constantly forms on your teeth. If plaque isn’t removed every day, it can turn the sugars found in most foods and drinks into acids that lead to decay. Bacteria in plaque also cause gingivitis and other periodontal diseases. It’s important to brush and floss correctly and thoroughly. You need to remove plaque from all sides of the tooth and where the tooth meets the gums. If plaque is not removed, it can lead to gum problems and cavities.

5 Limit snacks, particularly sugary snacks, and eat a balanced diet: Every time you eat, bits of food become lodged in and around your teeth. This food provides fuel for the bacteria in plaque. The bacteria produce acid. Each time you eat food containing sugars or starches (complex sugars), your teeth are exposed to these acids for 20 minutes or more. This occurs more often if you eat snacks, and the food stays on your teeth for a while. These repeated acid attacks can break down the enamel surface of your teeth, leading to a cavity. If you must snack, brush your teeth or chew sugarless gum afterward. A balanced diet is also important. Not getting enough minerals and vitamins can affect your oral health, as well as your general health.

6 If you use tobacco in any form, quit: Smoking or using smokeless tobacco increases your risk of oral cancer, gingivitis, periodontitis and tooth decay. Using tobacco also contributes to bad breath and stains on your teeth.

7 Examine your mouth regularly: Even if you visit your dentist regularly, you are in the best position to notice changes in your mouth. Your dentist and dental hygienist see you only a few times a year, but you can examine your mouth weekly to look for changes that might be of concern. These changes could include swollen gums, chipped teeth, discolored teeth, and sores or lesions on your gums, cheeks or tongue.

8 Visit the dental office regularly: Talk to your dentist about how often you should visit. If you have a history of cavities or crown and bridge work, or are wearing braces, you should visit the dentist more often. Some people, such as diabetics or smokers, have more gum disease than the general population. They also should visit the dentist more often. People with suppressed immune systems also are more likely to have dental problems. Examples include people who are infected with HIV or are receiving cancer treatment. More frequent visits for these groups are important to maintain good oral health.